Effectiveness of peer-led education interventions on contraceptive use, unmet need, and demand among adolescent girls in Gedeo Zone, South Ethiopia. A cluster randomized controlled trial

Peer-led sex education significantly boosts contraceptive use and demand while reducing unmet contraceptive needs among Ethiopian adolescent girls.


In developing countries, one-third of adolescent girls engage in unprotected sexual intercourse and do not use modern contraception – which can lead to early pregnancy, stillbirth, neonatal death, and medical complications. Girls face unique challenges regarding fertility preferences, access to services, and sociocultural factors, as the sexual health information provided to them is often not adapted to their values, and many adolescents are too embarrassed to discuss sexual matters openly.

What are the effective strategies we can use to engage and empower adolescent girls to discuss safe sexual behaviors and contraceptive use? School-based peer education – an environment relatively free from religious leaders, community members, and parental pressure – is proposed as a potential approach. Prior research indicates that peers have considerable influence over an adolescent's contraceptive choices, underscoring the vital role that friends and peers can play in fostering a supportive social environment for responsible contraceptive use.

The study evaluated the effectiveness of peer-led education interventions in schools to improve contraceptive use, unmet needs of contraceptives, and demand for contraceptives in sexually active adolescent girls in the Gedeo Zone, south Ethiopia.


Participating in peer-led education interventions resulted in an increase in contraceptive use and contraceptive demand and a decrease in unmet needs compared to the control group.

  • Contraceptive Use:
    • The intervention group reported a significant increase (26%) in the use of modern contraception, compared to the control group (0.9%). 
      Prior to the intervention, a statistically significant difference existed in contraceptive usage between the two groups. However, this disparity was not observed in the unmet need for contraceptives.
  • Unmet Needs:
    • Both groups reported a decrease in unmet needs. The intervention group saw a more pronounced reduction, with unmet needs for contraceptive devices decreasing (12.9%), compared to the control group (5.5%). 
  • Contraceptive Demand:
    • The intervention group reported a statistically significant increase in contraceptive demand (13.1%), compared to the control group who experienced a decline in demand (4.6%).

Sexually active adolescents in the intervention group were 8.7 times more likely to use contraception compared to the control group. The control group had a six times higher likelihood of unmet needs than the intervention group. After six months, the intervention group's contraception demand was six times higher than the control group. The study demonstrates a peer-led approach on safe sexual behaviors and contraceptive use could be a potential intervention to promote the use and demand of contraception among adolescent girls in low resource settings.


This study, conducted in the Gedeo Zone of Southern Ethiopia, focused on six governmental secondary schools to evaluate the effectiveness of peer-led education interventions among 218 eligible sexually active secondary school girls aged 15-19. These interventions focused on contraceptive use (the use of any one of the modern contraceptive methods during and after the intervention), unmet needs (the proportion of sexually active respondents who intended to use contraceptives but failed to do so during and after the intervention), and demand (the proportion of sexually active respondents currently using contraception or participants exposed to an unmet need for contraception during and after the intervention period). The overall average age of the participants was 16.97 years and over 80% of the participants were unmarried. Spanning from October 9th, 2021, to October 9th, 2022, it included 273 sections from grades 9 to 12 from the six schools, and employed a single-blinded school-based parallel randomized controlled trial with a cluster-randomized controlled design to avoid contamination. 

Following the SPIRIT (Standard Protocol Items Recommendations for Intervention Trials)  checklist, the clusters were the schools in the Zone. For randomization, schools were stratified and six were randomly selected, resulting in three intervention and three control groups. A 1:1 allocation ratio was implemented, with assignments placed in envelopes, and although allocation concealment was not feasible due to the nature of the intervention, data collection personnel were blinded to group assignments.

Four students and two biology and chemistry teachers were selected per school as peer educators and underwent a comprehensive 20-day training program. This program was initiated with 10 days of intensive teaching, discussions, and competitions on topics from reproductive health to practical demonstrations. An external team then provided additional training, concluding with written and oral exams, and only successful candidates were allowed to teach. The intervention was administered weekly for an hour over at least six months and employed participatory techniques like poems and role plays.

The study's methodological framework consisted of structured interventions and assessments for fidelity and standardization. Intervention materials covered introductions to sex organs, development of sexual negotiation skills, and information on pregnancy and contraceptives. Students were required to attend at least 80% of the sessions. Equal numbers of participants were drawn for the intervention and control groups, and the primary outcomes were assessed regarding contraceptive use, unmet needs, and demand. 

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